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Prostatitis

by Mark Wright

Definitions:

1. Pathological - where the inflammation is glandular, stromal or granulomatous. It can be acute or chronic and focal or diffuse. However, there is poor correlation between clinical findings and syndromes.

2. Urological - bacterial prostatitis which causes sepsis when acute and recurrent UTIs when chronic. Non bacterial prostatitis and prostadynia cause pain and inflammation. However, localisation studies are seldom done and less than 10% have bacterial prostatitis. Symptoms are frequently not associated with inflammation and infection.

New NIH Classification 1999

l.	Acute bacterial prostatitis	acute infection of prostate gland
ll.	Chronic bacterial prostatitis	recurrent UTI, chronic prostatic infection
lll.	Chronic Pelvic Pain Syndrome	discomfort in pelvis for >3 months, variable voiding, no demonstrable infection a) white cells in semen/EPS/VB3 b) no white cells in semen/EPS/VB3
lV.	Asymptomatic Inflammatory Prostatitis	evidence of inflammation in biopsy/semen/EPS/VB3, no symptoms

Epidemiology

Its has an estimated incidence of 5% of males aged 20-50 years. There were 500,000 office visits in the USA in 1994. In Canada, a urologist sees on average 262 cases per year, 38% of which are newly diagnosed with prostatitis.

Aetiology

1. Bacterial prostatitis
Infection may come from the rectal flora (transrectal, ascending urethral, STD) or bacteraemia/septicaemia.

Most Common	Less Common	Rare
E. Coli.	Klebsiella	Enterococci
	Enterobacter	Staphylococcus
	Proteus	Streptococcus
	Pseudomonas	Serratia

2. Chronic prostatitis/CPPS

dysfunctional high pressure voiding
intraprostatic ductal reflux
micro-organism based theory (biofilm bacteria, chlamydia, viruses etc.)
autoimmune
chemical - urine and its metabolites
neuromuscular
interstitial cystitis

Assessment:

a) Rule out urethritis and cystitis
This can be done with the Meares-Stamey test, microscopy and culture (+ve if > 10 wbc's/hpf).

Microscopy:

	VB1	VB2	EPS	VB3
Prostatitis	-	-	+	+
Urethritis	+	-	+	+
Cystitis	+	+	+	+

Microbiology (cfu/ml):

	VB1	VB2	EPS	VB3
Prostatitis	0-100	0	10,000	5000
Urethritis	1000	0	2000	800
Cystitis	10000	10000	10000	10000

b) Symptom assessment (NIH) questionnaire:

Acute bacterial prostatitis

Symptoms:
Fever, chills
Dysuria
M/s pain
Findings: prostate indurated and tender
Management:
Do not massage prostate
Analgesia, stool softener, hydration
Urinary retention > spc
Oral and IV antibiotics for 4 weeks can result in 95% cure (Lim AUA update XII)

Chronic bacterial prostatitis

Symptoms: recurrent UTI or asymptomatic
Findings: minimal tenderness on PR and +ve localisation cultures
Treatment: fluoroquinolone for 4-6 weeks

Drug dose	N	Days of treatment	Cure rate
Norflux. 800	20	23-42	92%
Norflux. 800	25	23	65%
Norflux. 800	15	14	53%

(Schaeffer AUA 1999)

Failures: low dose suppressive treatment > radical TUR
Chronic pelvic pain syndrome IIIa
Chronic pelvic pain syndrome IIIb - goal of therapy in this case is improvement rather than cure.

Feedback
Any comments, ideas or answers? Email edu@bui.ac.uk

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Page Last Updated 11 October, 2009